Web Consent

CONSENT FORM FOR
SET THERAPIST and SET CARPAL TUNNEL THERAPIST
WEB PAGE LISTING

Please print this form and send the completed form to the address below in order to be listed on the website:

Structural Energetic Therapy®, Inc
Attn: Pam Putnam
156-B Whitaker Road, Lutz, FL 33549

I hereby give permission to Structural Energetic Therapy®, Inc. to list my name as a Certified SET Therapist, or SET Graduate, or Certified SET Carpal Tunnel Therapist, office address, phone number, license numbers, and bio as stated below on the Structural Energetic Therapy® website for the purpose of locating trained Set Practitioners.

Name______________________________________________ FL Lic # : MA___________________

Address________________________________City________________State______Zip___________

Phone____________________Cell Ph______________Email________________________________

Certified SET Therapist: Yes____ No____ Certified SET Carpal Tunnel Therapist: Yes___ No___

Please write or attach a short bio that you would like included with your name on the web page: (i.e.
associations, length of time in massage, specialties, etc.)

_________________________________________________________________________________

If you wish to add a Hyperlink to your WEBSITE, submit your site address and included the one time administrative posting fee of $25.00 with this form.

STRUCTURAL ENERGETIC THERAPY®, INC.

CONSENT FORM FOR SET THERAPIST and SET CARPAL TUNNEL THERAPIST WEB PAGE LISTING

CONSENT FORM FOR
SET THERAPIST and SET CARPAL TUNNEL THERAPIST
WEB PAGE LISTING